What do we really know about treating refractory ventricular fibrillation? And why are we still waiting to use strategies that might actually work?

In this episode, we talk to Sheldon Cheskes about the evolving science of cardiac arrest, with a focus on refractory and recurrent ventricular fibrillation. We explore the evidence behind double sequential external defibrillation (DSED), how it compares to standard defibrillation, and what the DOSE VF trial has changed in practice.

This is not just about adding another shock. It’s about understanding why defibrillation fails, how vector and energy delivery matter, and when a different approach might improve outcomes.

We also discuss:

• The difference between refractory and recurrent VF — and why it matters

• What DSED and vector change actually do in physiological terms

• Why guidelines have been slow to move despite emerging evidence

• The role of antiarrhythmics, adrenaline, and sequence of care

• Practical considerations for introducing DSED into real systems

• What comes next — from smarter detection to post-arrest recovery

This is a conversation grounded in real-world resuscitation. It challenges current practice without overselling the evidence.

• Refractory VF (persistent after multiple shocks) and recurrent VF (returns after ROSC) are distinct clinical problems with different implications

• Double sequential external defibrillation (DSED) may improve outcomes in refractory VF by altering current pathways and myocardial depolarisation

• Timing matters — waiting too long to escalate may reduce the chance of success

• Current guidelines remain cautious, reflecting the balance between evidence and implementation risk

• Defibrillation strategy is only one part of a complex system that includes high-quality CPR, drug therapy, and post-resuscitation care

Cardiac arrest survival remains low.

Small improvements in early resuscitation can have large system-wide effects. Understanding when standard care is failing — and what to do next — is where expertise matters.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection.

The app is free to download, includes a one-month free trial, and offers globally adjusted pricing. If you are already listening, you may as well make it count.

You’re about to hear a conversation that ranges widely — from training reform and trauma leadership to ondansetron, paracetamol protocols, and artificial intelligence.

But it isn’t really about any single topic - It’s about where emergency medicine is heading. And whether we are ready for it.

This is our November and December 2025 round-up, and revisits the blog posts from the end of last year. A pause. A reset. A chance to look again at ideas that still matter on shift.

We explore

• The Medical Education Training Review and what it might mean for emergency medicine in the UK
• Flexibility, bottlenecks, and the portfolio route
• Why culture and team matter more than workload alone
• Trauma Team Leader tips — from missed wounds to managing presence in the room
• Ondansetron in paediatric gastroenteritis — symptom control or over-medicalisation?
• The SNAP protocol for paracetamol overdose in children
• How long it can take for good data to become everyday practice
• AI in the consultation room — and what happens when patients arrive with ChatGPT

What this means for trainers, medical schools, and the future of clinical judgement

This episode closes Season 12 of the St Emlyn’s podcast. Season 13 is coming — including London 2030 content and more from recent conferences.

Upcoming events

Tactical Trauma returns 2–4 November in Sundsvall, Sweden. It remains one of the most focused and practical trauma meetings in Europe — small faculty, serious discussion, no fluff. If you are interested in pre-hospital and in-hospital trauma care, it is worth your time.

IncrEMentuM is approaching fast, with limited places remaining. If you’ve heard us talk about it before, you’ll know why people come back.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection.

The app is free to download, includes a one-month free trial, and offers globally adjusted pricing. If you are already listening, you may as well make it count.

More conversations from recent meetings — including Trauma 2030 — will follow in upcoming episodes.

Thanks for listening

You’re about to hear a conversation about doing less. But it isn’t really about doing less. It’s about time.

Recorded at Trauma 2030 at the Royal College of Surgeons, this episode explores a shift in mindset in pre-hospital trauma care — away from maximal intervention on scene and towards rapid recognition of the patient who cannot be fixed pre-hospital.

I’m joined by Harriet Tucker — consultant at London’s Air Ambulance, HEMS Governance Lead at Air Ambulance Kent Surrey Sussex, and Trauma Team Leader at St George’s Major Trauma Centre — to talk about damage control pre-hospital care.

We discuss:

• Using time as a treatment

• Recognising non-compressible haemorrhage

• Why one line may be enough

• Moving interventions into the ambulance

• Changing the pre-alert

• The “pit stop” resus

• Taking patients straight to theatre

• Cultural resistance to doing less

• Governance, debrief, and looking after teams

This approach focuses on a small but critically unwell group of patients — often penetrating trauma with rapidly exsanguinating haemorrhage — where the only definitive treatment is surgical control of bleeding.

The key intervention is speed.

Harriet also discusses the governance work behind this change, the importance of reviewing every case, and how to bring ambulance services and in-hospital teams along with the shift in thinking.

This episode is part of a series recorded at Trauma 2030. More conversations from the meeting will follow in upcoming episodes.

Upcoming events

Harriet will be speaking at Tactical Trauma, 2–4 November, Sundsvall, Sweden.

IncrEMentuM is now only eight weeks away, with limited tickets remaining.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.

In this episode of the St Emlyn’s Podcast, we’re joined by Nigel Ruddell, Medical Director of the Northern Ireland Ambulance Service, recorded live at the BASICS Conference.

This is a conversation about Helicopter Emergency Medical Services (HEMS) — but not in the way you might expect.

It’s not really about aircraft. It’s about people.

Nigel talks us through the long, often uncomfortable journey to building Air Ambulance Northern Ireland. From early fundraising attempts in the 2000s, through the influence and legacy of Dr John Hinds, to the eventual partnership between charity and the statutory ambulance service that made a doctor–paramedic HEMS model possible.

We explore:

• Why the helicopter isn’t the intervention — the team is • The charity–NHS partnership model in Northern Ireland • Geography, rurality, and the realities of serving 1.9 million people • Dispatch challenges and the use of video triage (including the GoodSAM platform) • Cross-border working with the National Ambulance Service of Ireland • The cultural work required to convince colleagues that HEMS is not a “Cinderella service” • Humility, leadership, and the people who quietly build systems

We also reflect on John Hinds's legacy and how his passion catalysed change, including the significance of the Delta 7 callsign.

This is a thoughtful conversation about system design, pre-hospital care, and what it actually takes to introduce enhanced critical care capability into a region that has never had it before.

If you enjoy thinking about pre-hospital medicine, trauma systems, and the future of emergency care, you may also want to look at: the IncrEMentuM Conference and Tactical Trauma

And if you want to go deeper into the evidence behind the conversations we have on this podcast, explore MedPod Learn — now hosting nearly 5,000 medical podcast episodes with linked multiple-choice questions to support structured learning.

As always, thanks for listening.

In this episode of the St Emlyn’s Podcast, Iain Beardsell and Simon Carley talk with Caroline Leech at the BASICs Conference about resuscitative hysterotomy following maternal cardiac arrest.

This is a calm, evidence-led discussion of a rare, high-stakes intervention that most clinicians will encounter once, if at all — and still need to get right.

• Why the term resuscitative hysterotomy has replaced perimortem caesarean section

• The physiological rationale: relieving aortocaval compression to improve maternal resuscitation

• What the evidence actually shows about timing, maternal survival, and neonatal outcomes

• Findings from Caroline’s systematic review of out-of-hospital cardiac arrest in pregnancy

• Why the “4–5 minute rule” does not reflect real-world pre-hospital care

• Neonatal survival at far longer timelines than traditionally taught

• Practical decision-making in pre-hospital and emergency department settings

• Who should perform the procedure, and why speed matters more than seniority

• Aftercare challenges: open abdomen, placenta management, bleeding (or lack of it)

• Team cognitive load, role allocation, and when termination at scene is appropriate

• The emotional and professional impact on clinicians and families

• Maternal survival after out-of-hospital arrest is rare, but not zero

• Neonatal survival is higher than often appreciated, even with prolonged timelines

• Delaying purely to reach hospital or a specialist may reduce benefit

• The hardest part is not the incision — it is the decision, coordination, and aftermath

• Training should focus as much on judgement and communication as on technical skill

This episode is not about heroics. It is about realism, evidence, and being prepared for one of the most confronting moments in emergency care.

MedPod Learn is a medical podcast player designed to help turn listening into structured learning, with tools to support reflection, CPD, and appraisal.

Available on the App Store and Google Play.

IncrEMentuM was born to revolutionise how we approach emergency medicine. It’s not a traditional conference — it’s an immersive experience that pushes professionals to act, think, and make decisions in real time.

Our mission is to bring together healthcare providers, experts, and emergency personnel from around the world to share experiences, train in realistic scenarios, and test their skills under extreme pressure.

In 2026, we return with an even more intense and lifelike edition — all with one clear goal: to prepare you for what cannot be predicted.

This is an international conference covering various aspects of working in high-stakes environments, primarily related to pre-hospital trauma and critical care, with a tactical twist.

Our program is rich and diverse, featuring state-of-the-art lectures from world-class speakers. We aim to bring together all organisations working with pre-hospital trauma in tactical/hostile environments, including physicians, HEMS, EMS, police anti-terror units, military, fire and rescue services and more.

In this (rather delayed!) October round-up, Iain Beardsell and Simon Carley catch up on recent St Emlyn’s blog posts and papers that continue to shape emergency and resuscitation practice.

The discussion moves across trauma, analgesia, cardiac arrest physiology, emergency department systems, and antimicrobial stewardship—less about novelty, more about what actually holds up on shift.

The episode opens with a discussion of the FIRST-2 trial, examining fibrinogen concentrate and prothrombin complex concentrate versus fresh frozen plasma in severe traumatic haemorrhage. Despite promising physiological theory, the trial shows no meaningful reduction in blood product use compared with standard care, reinforcing the ongoing role of FFP in early trauma resuscitation.

The team explore the SUPERB trial comparing supraclavicular brachial plexus blocks with Bier’s blocks for upper limb reductions. Both techniques provide excellent analgesia. The conversation reflects on changing practice, procedural sedation pressures, ultrasound access, and how physical space—not evidence—often dictates what we do.

Three recent cardiac arrest papers are reviewed, focusing on physiological markers rather than new devices:

• End-tidal CO₂ as a CPR quality target

• Ventilation strategies during arrest, including chest-compression-synchronised ventilation

• Cerebral oximetry as a potential prognostic signal

These are not definitive answers, but they point towards cardiac arrest management that is more physiological and less ritualistic.

A reflective discussion on “designer repair” challenges the idea that emergency departments need constant transformation. Instead, the focus shifts to recognising and supporting the clinicians quietly holding fragile systems together every day—and why fixing small, broken things often matters more than grand redesigns.

The episode closes with a critical look at broad-spectrum antibiotic use in suspected sepsis. Observational data suggest significant overtreatment and real harm, reinforcing the need to pause, think, and choose the right antibiotic—not just the fastest one.

This episode is a reminder that good emergency medicine is rarely about silver bullets. It’s about judgement, physiology, and paying attention to what actually works in the real world.

MedPod Learn is a medical podcast player designed to help turn listening into structured learning, with tools to support reflection, CPD, and appraisal. Available on the App Store and Google Play.

This bonus episode is a quick-fire collection of clinical pearls drawn from across the St Emlyn’s podcast in 2025.

Short, practical, and deliberately focused, these are the moments that make you stop and think: “That’s useful — I want that in my head.”

There’s minimal commentary and no deep dives. Each clip stands on its own as a clear takeaway, designed to be listened to in one go or dipped back into when needed.

• Practical triage language that lowers thresholds and prompts earlier action

• Time-critical decision-making in pre-hospital thoracotomy

• Resuscitation physiology and why diastolic pressure matters

• Intraosseous access and the reality of long-term complications

• Analgesia strategies for rib fractures, including posterior injuries

• Hydrofluoric acid burns and why improvised treatment is a trap

• Recognising and acting on decompression illness

• Cognitive HALOs and preparing for rare, high-load decision moments

• Building excellence in teams, not just avoiding failure

• Compassionate resuscitation and the value of the pause

This episode is designed to be saved, revisited, and shared — the kind of learning that pays off later.

Clips in this episode are taken from the following full St Emlyn’s episodes:

• Episode 257 — Ten Second Triage with Sean Brayford-Harris

• Episode 270 — Insights on Cannabis Edibles, Pre-Hospital Thoracotomy and more

• Episode 266 — Monthly Round Up (February 2025): Skills Fade and Resuscitation Targets

• Episode 260 — Monthly Round Up (December 2024): IO Access and Chest Trauma

• Episode 268 — Top Papers of 2024 from The Big Sick Conference

• Episode 275 — Targeted Resuscitation and Hydrofluoric Acid Burns

• Episode 263 — Hyperbaric Medicine with Jeff Kerrie

• Episode 277 — Cognitive HALOs and Advanced Simulation Training

• Episode 264 — High Performance Teams with Dan Dworkis

• Episode 258 — Compassionate Resuscitation with Matt Hooper

All full episodes are available in the podcast feed.

MedPod Learn is a medical podcast player designed to help turn listening into structured learning, with tools to support reflection, CPD, and appraisal. Available on the App Store and Google Play.

Some of the hardest moments in emergency medicine aren’t hard because they’re complicated. They’re hard because they’re rare — and when they arrive, you’re relying on things you last thought about a long time ago.

This final episode in the Best Bits of 2025 series is the “file it away” collection: rare, high-stakes situations where preparation is largely cognitive, decisions are time-critical, and there may be no second chance.

The clips in this episode are drawn from full St Emlyn’s episodes released during 2025 and focus on recognition, decision-making, and human factors in uncommon but consequential scenarios.

• How community response and live video have changed what happens before patients reach hospital

• Recognising and acting on decompression illness, even when presentations are subtle

• Cognitive HALOs — what happens to our thinking in rare, high-acuity situations

• Junctional haemorrhage and the role of the abdominal aortic junctional tourniquet

• Human decision-making under extreme pressure, illustrated through aviation medicine

This episode is designed to be listened to slowly, and returned to when needed — the kind of learning that pays off long after you first hear it.

Clips in this episode are taken from the following full St Emlyn’s episodes:

• Episode 262 — GoodSAM Update with Mark Wilson (London Trauma Conference)

• Episode 263 — Hyperbaric Medicine with Jeff Kerrie (London Trauma Conference)

• Episode 277 — Cognitive HALOs and Advanced Simulation Training with Halden Hutchinson-Bazely (BASICs)

• Episode 273 — Abdominal Aortic Junctional Tourniquet with Ed Barnard

• Episode 276 — Ejection Seats and the Injured Pilot with Phil Lucas (BASICs)

All full episodes are available in the podcast feed.

MedPod Learn is a medical podcast player designed to help turn listening into structured learning, with tools to support reflection, CPD, and appraisal. Available on the App Store and Google Play.